Brain injury hidden factor in homelessness

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Ruben Michael manages a crew of Downtown Streets Team workers, including William Cochran in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

Ruben Michael works on the Downtown Streets Team sweeping along University Avenue in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

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Ruben Michael works on the Downtown Streets Team keeping University Avenue clean in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

Ruben Michael manages a crew of Downtown Streets Team workers, including William Cochran in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

Ruben Michael works on the Downtown Streets team sweeping along University Avenue in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

Ruben Michael works on the Downtown Streets Team sweeping along University Avenue in Palo Alto, Calif., Tuesday morning, July 14, 2015. Michael was diagnosed with cognitive impairment earlier this year and was approved for disability. (Karl Mondon/Bay Area News Group)

SAN JOSE — Ruben Michael’s story of slipping into homelessness has familiar themes. Job loss. Depression. Drinking. Then eventually, a life on the streets.

But his descent might be typical in another way. It wasn’t until earlier this year, long after Michael became homeless, that he was diagnosed with brain impairment — something new research suggests may be a hidden reason why many of the chronically homeless keep returning to the streets despite programs to help them find housing and kick their addictions.

“It explained a lot because I don’t remember things,” said Michael, 58, who mostly has been without housing since 2006.

And he’s hardly alone when it comes to homeless dealing with undiagnosed cognitive problems. The Valley Homeless Healthcare Program screened several dozen patients and found that 71 percent suffered from some type of impairment such as a traumatic brain injury.

The findings, although from a relatively small sample size, suggest that brain issues may be a hidden factor in why people end up living along creeks or in parks.

“This gives us a better understanding about the cause of homelessness,” said Charles Preston, director of psychology services at the program, which is part of the Santa Clara Valley Medical Center. “It’s something we had never even contemplated. But once you know that it’s a contributing factor, you realize why people sometimes don’t last in housing if you’re not also helping them with the right services.”

Addictions and mental illness long have been associated with homelessness. But a link between brain injury and homelessness is not well understood. It wasn’t until Ciara Mahan, a county psychologist at the HomeFirst medical respite, began screening for cognitive problems that a startling pattern emerged.

“It helps explain why some homeless can’t form new memories or do something like make the correct bus fare,” Mahan said. “Some of these people are really smart, but they have poor decision-making abilities or a basic inability to understand what’s being said. So many homeless also are angry and argumentative, but we’re seeing a medical reason why they act that way.”

Awareness about the long-term effects of brain injuries is growing. Brain injury became the signature wound of the post-9/11 wars as military personnel endured sudden bomb blasts in Iraq and Afghanistan. Also, there has been a newfound understanding of the toll that repeated sports collisions — such as those in football — can have on the brain.

TBI is the disruption of normal brain activity. Symptoms can include dizziness, headaches, insomnia, memory problems, trouble maintaining focus, irritability and an inability to interact with others.

The homeless program, which treats about 7,000 patients each year, sees those traits every day.

“If they’ve been homeless long enough, they’re going to have head injuries,” Preston said. “Our people tend to fall down a lot. They get hit by cars. It’s hard to say if they had cognitive impairment before they became homeless or they became homeless and then developed problems. But what we can say is the homeless have cognitive problems that are astronomical compared to the general public.”

Mahan screened 76 patients at the medical respite, where homeless patients who are discharged from the hospital can continue to recover. She found that 83 percent who took the short Montreal Cognitive Assessment test scored below the impairment level. Because substance abuse and mental illness can affect the score, Mahan didn’t count borderline cases — resulting in the 71 percent figure.

While the research has not been published, Mahan and Preston have presented the data at conferences for health care professionals who treat homeless. Their findings echo a study published last year in Canada.

Jane Topolovec-Vranic, a researcher at St. Michael’s Hospital in Toronto, examined 111 homeless men at a city shelter and determined that 45 percent had suffered TBI.

“You could see how it would happen,” Topolovec-Vranic told Time magazine. “You have a concussion and you can’t concentrate or focus. Their thinking abilities and personalities change. They can’t manage at work, and they may lose their job, and eventually lose their families. And then it’s a negative spiral.”

Michael’s spiral began in about 2006 with a job loss. While he had attributed his memory issues mostly to drinking, he also was in a vehicle accident as a youth.

“I cracked my head and was in a coma,” he said. “It was pretty bad. I remember the doctor telling my mother that I might have some symptoms in the future — like loss of memory.”

But it was something he hid well, until undergoing a battery of tests this year.

“Ruben is an example of people we’re missing because he’s very good at covering up his memory problems or if he doesn’t understand something,” Preston said.

Now sober and working for the nonprofit Downtown Streets Team in Palo Alto, Michael couch surfs at a friend’s place some nights and spends others sleeping in his truck. He hopes to return to stable housing.

Meanwhile, psychologists believe the data — which Mahan continues to collect — will help in the ongoing discussion of how best to help people off the streets. The trend is toward a “housing-first” model in which homeless are placed in housing and then supported with services.

Mahan’s concern is that people with cognitive impairment will relapse into homelessness. She would like another option to be considered — group homes.

“Unfortunately, if we put people with severe cognitive problems in independent-living environments, it’s inevitable they will fail,” she said. “With at least an interim program, they might eventually be ready.”

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